Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Waters Of Cheatham, Llc during CMS and state inspections, most recent first.
The facility failed to ensure a qualified Infection Preventionist was employed part-time to oversee the IPCP. Policy required an appointed licensed nurse to serve as the IP and conduct weekly rounds, and CMS guidance required an onsite, specially trained IP. Surveyors found no documentation of a part-time IP; the interim DON could not produce proof of prior training, the ADON had completed only 7 of 12 required modules, and the Regional DON had the certificate but did not work onsite part-time.
A facility failed to complete and document physician-ordered wound care for two residents with sacral pressure injuries. One resident had a stage 4 sacral ulcer with orders for daily cleansing, medihoney, calcium alginate packing, and a border foam dressing, but the MAR showed multiple missed entries. Another resident had a stage 3 sacral wound with daily NS cleansing, collagen, and border foam dressing orders, but the TAR showed multiple missed treatments. The ADON and DON stated the records should not have blanks and that missing charting meant the care was not proven to have been delivered.
Inaccurate PBJ Staffing Data Submission: The facility failed to submit accurate direct care staffing data to CMS for PBJ Q1. Review of the PBJ Staffing Data Report showed excessively low weekend staffing, and licensure staffing records for multiple weekends showed staffing percentages between 2.25% and 3.86%. The Administrator stated the DON was not calculating the information correctly and that the timeclock system did not calculate hours immediately, confirming the PBJ data reported was incorrect.
The facility failed to maintain the 400 Hall women's and men's communal bathrooms in working condition. One women's commode was bagged out of service and the other leaked at the back, while both men's commodes leaked, the light was dim with an out bulb, and mold was observed on an adjacent wall. Residents and staff reported the problems had been ongoing for weeks to months, with water on the floor and towels or bath blankets placed under the toilets.
Failure to provide individualized activities and document participation. Several residents with varying cognitive and physical conditions had care plans calling for structured activities, 1:1 sessions, reminiscence, diversionary programming, or outdoor time, yet there was no documentation that activities were offered or provided during the review period. Residents were observed sleeping in bed with no TV or radio, and some stated they were not being visited, had nothing to do on weekends, or wanted to go outside but could not. The AD, SSD, and DON all acknowledged gaps in activity charting and resident access to activities.
Failure to Post Daily Nurse Staffing Information: The facility did not post the daily nurse staffing information for licensed and unlicensed staff responsible for resident care. Observations at the nurse's station over 3 days showed the required staffing details were not posted, despite facility policy requiring daily posting at the beginning of each shift. The Interim DON and Administrator both confirmed that daily staffing information was expected to be posted.
Qualified Infection Preventionist Not Employed Part-Time
Penalty
Summary
The facility failed to ensure employment of a qualified Infection Control Preventionist to monitor and maintain the Infection Prevention and Control Program. The facility policy stated that an appointed licensed nurse would spearhead the program as the Infection Preventionist and make facility-wide rounds at least weekly to identify breaches in the physical environment. Survey review also cited CMS guidance stating that facilities must have a part-time Infection Preventionist who physically works onsite and has specialized training. During review and interview, the facility was unable to provide documentation showing that it had an Infection Preventionist working at least part-time. The interim DON said she had completed infection control training for Infection Preventionist many years ago but could not provide documentation. The newly hired ADON had completed only 7 of the 12 required training modules, while the Regional DON had the required training certificate but did not physically work at the facility part-time. The deficiency was identified as affecting 54 of 54 residents.
Missed wound care and incomplete documentation for two residents with sacral pressure injuries
Penalty
Summary
The facility failed to ensure wound assessments and physician-ordered treatments were completed correctly for 2 of 4 residents reviewed for pressure ulcers/wounds. Facility policy required residents with pressure ulcers to receive necessary treatment and services consistent with professional standards of practice, and required physician orders to be implemented and followed as received. The report identified missed wound care documentation and treatment entries for two residents with sacral pressure injuries. Resident #8 was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, diabetes, a stage 4 sacral pressure ulcer, and osteomyelitis of the vertebral, sacral, and sacrococcygeal region. The care plan identified a stage IV sacral wound present on admission with treatment per physician orders. A physician order directed cleansing the stage 4 sacral wound with Dakin's solution, applying medihoney to calcium alginate packing, and covering with a border foam dressing daily on day shift. Review of the MAR showed no treatments completed on multiple days in March. During interview, the ADON stated the wound care was moved between shifts and was not marked off, and the DON stated that the MAR did not prove the care was delivered and showed care was not delivered. Resident #51 was admitted with diagnoses including vascular dementia, psychosis, morbid obesity, and diabetes, and had a BIMS score of 15 indicating cognitive intactness. The resident had significant lower-extremity impairment and was dependent or required substantial to maximal assistance for mobility and transfers. A wound assessment identified an in-house acquired stage 3 sacral pressure injury, and a physician order directed cleansing the wound with normal saline, applying a collagen sheet and border foam dressing daily and as needed on day shift. Review of the TAR showed missed wound care entries on multiple dates in late February and March. The ADON stated the treatment was likely done but not clicked off, and the Interim DON stated there should not be blanks on the TAR.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS for PBJ Quarter 1, based on payroll and other verifiable and auditable data. Review of the CMS Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual dated June 2025 showed that direct care staffing and census data are collected quarterly and are required to be timely and accurate. Review of the PBJ Staffing Data Report for Quarter 1 of 2026 revealed excessively low weekend staffing, and review of the facility’s licensure staffing requirements for multiple weekend dates between October 1, 2025 and December 31, 2025 showed weekend staffing percentages ranging from 2.25% to 3.86%. The facility’s licensure staffing documentation indicated that the Quarter 1 PBJ information was reported inaccurately. During an interview on 3/16/2026 at 11:47 AM, the Administrator stated that the DON at the time was not calculating the information correctly and that the system used did not calculate hours based on timeclock punches correctly immediately, noting it could be 1 or 2 days later. The Administrator confirmed that the Quarter 1 PBJ information reported was incorrect.
Leaking communal bathrooms and out-of-order fixtures
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for the 400 Hall women's communal bathroom and the 400 Hall men's communal bathroom. Facility policy required restroom daily cleaning to maintain a clean, orderly, and attractive environment and to inspect and report equipment damage or needed repairs. The Administrator's job description also required regular rounds to monitor cleanliness and appearance of the facility, but the bathrooms remained in poor condition during multiple observations and interviews. The women's communal bathroom had two commodes, but only one was available for use because the second commode was bagged with a plastic bag and a plunger placed on top of it. The remaining commode was leaking at the back of the toilet. A resident who used the bathroom reported that water had been on the floor and that her wheelchair had been soaked, and she said she no longer used that bathroom and instead went to another hall to use a bathroom. Another resident stated that the second commode had started leaking, then leaked more strongly, and had been unusable for at least a month. Staff also stated that the bathroom had been out of use for about a month. The men's communal bathroom also had two commodes, and both were reported to be leaking. Observations showed a dim light with an out bulb, a wet towel under one commode, a wet shower cape under the other, mold on the adjacent wall, and visible leaking from the top of the plumbing down the side of the commode and onto the floor. A resident who used the bathroom stated that water had been on the floor and his wheelchair had been soaked, and he no longer used that bathroom. Staff stated the men's bathroom commodes had been leaking for a couple of months, that towels or bath blankets had been placed under both commodes because they leaked, and that the light bulbs stayed out. The Housekeeping Supervisor and CNA both acknowledged the ongoing leaks, and the Administrator stated she did not use those bathrooms and was unaware of their condition until the issue was raised.
Failure to Provide Individualized Activities and Document Participation
Penalty
Summary
The facility failed to provide an ongoing activities program designed to meet the interests, physical, mental, and psychosocial well-being of 7 of 10 sampled residents. Facility policy stated residents had the right to participate in an activities program designed to meet their needs, and the Activities Program policy stated the facility would provide ongoing activities in accordance with residents’ interests and well-being, including 1:1 programming for residents unable or unwilling to attend group activities and staff assistance with transportation to and from activities. Resident #5 had diagnoses including CHF, chronic pulmonary edema, cognitive communication deficit, and hypertension, and an MDS BIMS score of 4 indicating severe cognitive impairment. The care plan directed simple, structured activities and reminiscence with family photos, but there was no documentation that activities were provided or offered for the month reviewed. The resident’s representative stated he loved bingo but was unsure whether he was getting to go, and the resident stated he used to play bingo and enjoyed it. During observation, no TV was playing and no radio was beside the bed for music stimulation. Resident #9 had Alzheimer’s disease, anxiety disorder, and major depressive disorder, with an MDS showing poor short- and long-term memory recall. The care plan called for low-functioning activity programming, 1:1 sessions, sensory and environmental stimulation, and diversionary activities, but there was no documentation of activities being provided or offered during the review period. The resident was observed sleeping or lying in bed facing the wall on multiple occasions, with no TV on and no radio beside the bed. Resident #22, who had Alzheimer’s disease, vascular dementia, anxiety disorder, and major depressive disorder, had a BIMS score of 14 and a care plan calling for simple structured activities and a program accommodating abilities, yet there was no documentation of activities being provided or offered, and the resident was observed sleeping with no TV or radio present. Resident #26, with diabetes mellitus, cognitive communication deficit, and major depressive disorder, had a BIMS score of 12 and a care plan for friendly visits and diversionary activities, but there was no documentation of activities being provided or offered; the resident stated she slept most of the day and did not think the Activity Director came by or talked with her, and no radio was present. Resident #29 had anemia, hyperlipidemia, hypertension, and anxiety disorder, with a BIMS score of 14 and a care plan noting interests in walks outside, people watching, games, bingo, baking, volunteering, and courtyard time. There was no documentation of activities being provided or offered, and the resident stated there was nothing to do on weekends, that she wanted to go outside but no one could go with her, and that going out with smokers was undesirable. Resident #41 had hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, and anxiety disorder, with a BIMS score of 10 and a care plan for low-functioning activity programming and reminiscence, but there was no documentation of activities being provided or offered; the resident was observed sleeping in bed with no TV or radio. Resident #54 had hemiplegia and hemiparesis, cerebral infarction, major depressive disorder, and anxiety disorder, with a BIMS score of 14 and a care plan for reminiscence, but there was no documentation of activities being provided or offered, and the resident was observed sleeping with no TV or radio. During interview, the Activity Director stated CNA staff charted activities in the electronic system, but when asked for activity participation over the last month, she produced handwritten sheets listing resident names and dates only, without the activity provided or resident response, and stated that without documentation she could not prove it happened. She also stated weekend activities were attempted by management but were not charted. The SSD stated CNAs had an activity tab to chart, and residents had complained about no weekend activities and about wanting to go outside without having to go around smokers. The DON acknowledged that residents who do not attend group activities should be provided 1:1 activities and stated residents who request to go outside should be allowed to go out.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information for licensed and unlicensed staff responsible for resident care was posted daily for 3 of 3 days reviewed. Facility policy titled, "Guidelines for BIPA Staffing Posting Requirements," dated 7/24/23, stated that the facility must post daily, at the beginning of each shift, the facility-specific shift schedule for the 24-hour period, the number and category of nursing staff employed or contracted for each 24-hour period, and the total number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care. Observations at the nurse's station on 3/23/2026 at 9:55 AM, 1:30 PM, and 4:35 PM showed the daily number of licensed and unlicensed nursing staff was not posted. Similar observations on 3/24/2026 at 7:30 AM, 1:45 PM, and 3:15 PM, and on 3/25/2026 at 7:35 AM, 10:00 AM, and 2:45 PM, also showed the staffing information was not posted. During interviews, the Interim DON and the Administrator both stated that staffing information was expected to be posted daily.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ashland City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Healthcare Center | 3.7 mi | ★★★★★ | 13 | 0 |
| Eaton Creek Post Acute | 10.6 mi | — | 0 | 0 |
| The Meadows | 11.5 mi | ★★★★★ | 0 | 0 |
| West Meade Place | 13 mi | ★★★★★ | 9 | 0 |
| Whites Creek Wellness And Rehabilitation Center | 13.7 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.